Brighton Journal of Research in Health Sciences

Supporting Research in the School of Health Sciences


Promoting young people’s resilience through enjoyable structured activities.


Concerns about child protection and wellbeing have been increasing in the UK (Kids Company 2014) and internationally (WHO 2012), particularly for those experiencing significant adversity. Such adversity has been defined as intense and/or persistent negative life events including: neglect, abuse, poverty, mental health challenges, addictions, disability and discrimination (Hart et al 2007). Lack of appropriate supports to respond to adversity can have a detrimental impact on children’s development and adult life (Masten and Cicchetti 2010). Resilience involves a dynamic process of positive adaptation to adversity and, accordingly, a resilience frame of reference can facilitate the understanding of young peoples’ strengths and challenges (Hart et al 2007, Masten 2011). Assessing resilience requires taking into account assets and resources within an individual and their environment, and longitudinal processes that lead to resilient outcomes (Ungar 2009). Successful recovery from adversities can contribute to future resilience and debate has focused on internal factors and external factors that may promote resilience (Rutter 2012); yet an occupational perspective (Wilcock and Hocking 2014) calls attention to the potential role of human doing which involves an interaction of internal capacity with the external world.

Literature review

Current resilience research employs multidisciplinary approaches to investigate how individual and environmental factors work together to promote resilience among the most disadvantaged youth (Hart et al 2007, Masten 2011). This includes expanding the evidence base for activity-based interventions (Hart and Heaver 2013) and exploring the perspectives of the professionals involved (Teram and Ungar 2009). A resilience research project, Imagine (2015), has proposed investigating past resilience-building strategies to facilitate reflection on current practices and enhance service provision.

Some studies suggest that activity participation can enhance resilience in young people through development of positive self-identity, including improvement in self-esteem, sense of control, self-awareness, coping, taking care of themselves, confidence, belonging, satisfaction, goal-orientated behaviour and optimism (DeLuca et al 2010, Hart and Heaver 2013, Scholl et al 2004, Woodier 2011). Accordingly, Jessup et al (2010) and Grunstein and Nutbeam’s (2007) found leisure activities promoted all of the above.

Participation in leisure activities and apprenticeships has been linked to the resilience indicators of improved learning outcomes, and development of new roles and responsibilities (Hart et al 2007, Ungar 2009). A robust study (Scholl et al 2004) found that graduates with and without disabilities from a youth apprenticeship programme reported advancement in their technical, communication, problem-solving and time-management skills, and made meaningful work transitions with appropriate support. Other studies identified a positive impact of leisure or vocational activities on school performance and further education (DeLuca et al 2010, Hart and Heaver 2013, Jessup et al 2010, Woodier 2011).

Developing friendships, interpersonal skills and belonging to supportive relationships is another resilience domain (Hart et al 2007, Masten 2011) associated with activity participation (Grunstein and Nutbeam 2007, Hart and Heaver 2013, Scholl et al 2004, Woodier 2011). DeLuca et al (2010) illustrates the important role of support and guidance in facilitating these positive outcomes. Two case studies were compared and demonstrated that appropriately graded adult assistance during an apprenticeship promoted positive personal, inter-personal and work outcomes. Conversely, lack of support was found to result in gradual disengagement until help was provided.

These findings are consistent with Wilcock and Hocking’s (2014) theory that through doing people shape who they are – they become – particularly as they move into adulthood. Thus receiving professional support and belonging to a social group appears to be important in promoting occupational wellbeing and resilience. Participation in appropriately structured play/leisure, exercise and employment related activities may address occupational injustice and the resilience indicator of meeting basic needs (Hart et al 2007, Masten 2011, Ungar 2009).

Evidence suggests that activity participation can promote resilience, however, the studies reviewed have a number of methodological limitations, including the lack of detailed description of settings, participants and interventions. Only Jessup et al’s (2010) research focused on leisure activities and only one study (Woodier 2011) was UK-based. Of the studies which included practitioners’ perspectives (DeLuca et al 2010, Woodier 2011) – just DeLuca et al (2010) provided in depth description of specific practitioner support strategies used to promote resilience.

Some longitudinal studies ranging up to three years were identified, but no papers presented accounts of past practices. Historical research may help to capture the complex processes of adversity and the use of occupational strategies in adapting to life transitions, including the change in availability of adequate supports (Kirk and Wall 2010, Wiseman and Whiteford 2007). Research into past practices may illuminate changes in both individual and organisational resilience over time. The research reported below explored the role activities have played in service provision over recent decades and its impact on youth resilience.

Reviewing the current literature led to the formulation of the following research question: how did retired professionals use activities to promote the resilience of young people they previously supported?


Study design

Ethical approval for this study was granted by the relevant University Research Ethics Panel. A qualitative approach was chosen for this exploratory study (Silverman 2010) underpinned by a critical realist ontological and epistemological position (Danermark et al 2002). This methodology holds that while every vulnerable youth experiences their situation of adversity subjectively, the reality of the adverse circumstances exists independently of that experience. Therefore it is valid for critical realist research to try and identify explanations for phenomena which may be relevant to different individuals in related contexts. The impact of the researcher’s experiences and views was acknowledged in line with a critical realist perspective that interpretations of reality will vary according to the perceptions and attributes of different people (Archer 1995). In-depth interviews were conducted with retired professionals to gain accounts on how they had previously used activities to promote young people’s resilience.


Purposive (snowball and criterion) sampling was used to recruit five participants allowing gathering of rich information within limited time constrains (Silverman 2010). The participants were retired people aged over 60 who had worked in health, social care and education and who used activity-based strategies to promote resilience in young people (aged 12-18) experiencing adversity in the UK. Participants were able to give their consent, had fluent English and confirmed that the young people they discussed were over 18 at the time of the research interview. The first five respondents were interviewed.


After consent was gained, approximately 80 minutes long interviews were carried out on university premises using semi-structured open questions, examples of which participants were given in advance. The questions included ‘Could you describe how you used an activity with a young person you worked with?’, ‘Could you describe the types of adverse situations the young person was going through?’ and ‘How did the activity engagement make a difference in the life of…?’ These questions were informed by resilience literature (Masten 2011, Ungar 2009) and discussions with boingboing resilience forum members (boingboing 2013), and their utility was confirmed by a pilot interview. During the interviews further prompts were given to encourage participants to expand or clarify particular points. These interviews were audio-taped and transcribed using pseudonyms to ensure confidentiality.

Data analysis

Data were analysed using a two stage narrative analysis methodology as rich narrative accounts can help to understand the meaning and social significance of the activities in a particular context (Polkinghorne 2010). The first stage was the creation of a chronologically organised core story with a beginning, a middle, an end and contextual factors (Clandinin and Connelly 2000). This chronological picture of the events afforded the potential to suggest the difference the activity participation made (Polkinghorne 2010). The second stage was interpretative and involved looking for regularly reoccurring themes within individual narratives and across them (Clandinin and Connelly 2000). Some themes emerged from the data and some were informed by the authors’ existing understanding of wider literature thus a combination of inductive and deductive approaches were used consistent with the critical realist methodology (Danermark et al 2002).

Credibility was enhanced through member checking in which participants were invited to comment on the key themes (Silverman 2010). The researcher also used a reflective journal throughout the duration of the research to ensure the confirmability.


The five participants came from social work, family therapy and teaching professions. Their detailed narratives covered periods of up to thirty years from the present. 12-18 years old youths’ experiences of adversity were found to be related to bereavement, trauma, anger management, anxiety, poverty, social deprivation, domestic violence and disabilities. The background characteristics of participants are described in table 1 below and a summary of their reported activity-based interventions for young people are shown in table 2. (Names of all individuals and organisations have been changed to protect anonymity).

Table 1. Participant practice information

Participants reflected on the most recent 10 years before they retired.

  • Matt – began career as youth worker in 1970s subsequently qualified as a social worker and then as a family therapist. Retired in 2012.
  • Jude worked as Special Educational Needs Co-ordinator in schools and nurseries since 1980s. Alongside that she volunteered at the Sparkle – a charitable organisation that provided weekly activities and occasional trips. Retired in 2013.
  • Sam – social worker at the Rainbow – a country-side based residential place offering ‘youth in trouble’ support to engage in constructive activities over the weekends. Retired 30 years ago.
  • Pat – qualified as social worker in 1980s. Discussed experiences at The Sunshine – a centre supporting children with learning and physical disabilities. Retired in 2012.
  • Ruth qualified as a primary school teacher in 1970s. Also volunteered with various youth organisations. Retired in 1990s.

Table 2. Summary of young people’s background, interventions and outcomes.

The adversities faced by young people:

  • Antisocial behaviours: stealing, lying, aggression, violence, property damage, youth offending.
  • Poor school performance/attendance/suspended.
  • Childhood trauma, including parent’s death, divorce, illness, single parenting, drinking, unemployment, chaotic routines, abuse, domestic violence, ‘bad parenting’.
  • Physical, mental health and learning difficulties/disabilities, substance misuse.
  • Poverty and financial struggles.

Activities used:

Mindfulness, family therapy, liaising with school and parents, (international) camping trips, running hip-hop groups, cooking, making beds, looking after chickens, Qi Gong, games, roller-skating, football, ice-skating, canoeing, walking in the woods, gardening, painting, knitting, visiting theatre, volunteering, psycho-education.


– representing mechanisms and contextual factors associated with participation in structured activities which influenced young people’s resilience – were identified from the data. These were: promoting positive emotional experience and expression; developing routines, responsibility and roles; constructive relationships; and, social policy and service-level change. These themes are presented in further detail below.

Promoting positive emotional experience and expression

Most participants stated that activity engagement promoted positive emotions in youth. Special Educational Needs Co-ordinator (SENCO) Jude explained that the games they play should always be fun. “That’s the whole essence of it in my mind. If they’re fun, then the children enjoy playing them.” While most enjoyed exploring a variety of activities, gardening was the only occupation that Eva took pleasure in and benefited from. “Everybody else was at the same stage as she was. She felt more at ease, […] less tense, more amenable and interested in what would happen – to see the flowers come out, the tomatoes forming”, reflected primary school teacher Ruth.

Activity enjoyment was also linked to increased confidence and self-esteem. For example, Bob was bullied at school and was never picked to play football, one of his favourite sports, as “macho boys would pick big guys” to join their team. The staff arranged for him to beselected, and “he was good at it – very quick and agile. […] The next time the other team wanted him as well”, remembered social worker Sam. This helped to build his self-respect, confidence and maturity – “he would not accept being bullied anymore”. This shows that increased resilience can enhance youth’s ability to both cope with and challenge adversity.

Family therapist Matt considered that embodied meditative activities transformed negative energy into positive and aided emotional and physical healing. “Sara could write a book on anxiety management. But in her body she was still experiencing huge anxiety’, recalled Matt. She stopped going to school and spent her days in bed. Qi Gong helped her to use negative anxious energy in her body, gather warm calm positive energy, placing and storing it in her lower belly. A few months later Sara returned to school and was relatively free from Irritable Bowell Syndrome.

Similarly, mindfulness-based approaches helped Paul to develop awareness and management of his anger enabling him to be happier and work towards his aspirations. Mindfulness helped Paul to notice the physical sensations in his hands, and how this related to his thoughts and feelings. “If you notice your hands clenching, is that happening when you are relaxed, tense, feeling angry? If the hands are relaxed, then you are relaxed”, explained Matt. Paul had to physically release his hands when they were tensing up. “With kids, if you get them to work with their bodies, it’s much easier than getting them to work with their emotions.” Paul did not get involved in any further violence. He returned to college and did well, aspiring to enter the same skilled trade as his father. Such enjoyable and meditative activities helped promote healing, active engagement, positive self-image and confidence.

Developing routines, responsibility and roles.

Improvement in structured routines, learning, sense of responsibility and future transitions was another category of reported resilience outcomes. Some young people had difficulties with following structured routines due to “chaotic” home environments, explained social worker Sam. A countryside-based residential home ‘Rainbow’ provided them with such opportunities for up to three days a week. They had to get up at certain time in the morning, help to make beds and prepare meals (some discovered they liked vegetables).

On occasions occupational participation involved disappointments and subsequent feelings of guilt, which, when reflected upon, could foster a better understanding of the consequences of their actions and a stronger sense of responsibility. Sam explained, “The big boys would go out and make sure the fox does not get any chickens. One day the fox got some of the chickens and they were very sad about that. Next time they would make sure the fox would never get any chickens.”

Improvement in anti-social behaviours could arise from being encouraged to take responsibility. Jude described how one boy “was at his best [and enjoyed himself] when I said ‘Will you push the wheelchair?’ […] Other times, I remember at one camp where he was on the top of that dung heap swearing loudly as people were passing. Give him a bit of responsibility, and […] he could rise to the occasion and do well and be successful.”

All the professionals wondered if the resilience that the activity promoted at the time had supported future transitions. There was evidence of improved school attendance and performance as Sara’s and Paul’s stories demonstrated, and they subsequently expressed clear aspirations for the future. Primary school teacher Ruth reflected that development of interests and skills could influence career choices. “It was amazing how some children would learn to cook, get a badge and eventually become a chef.” . Sometimes small improvements were observed while other times professionals were uncertain as to whether resilience was carried into home and school environments.

For some resilience only really manifested itself in adulthood. For example, Nora presented with difficult behaviours at the youth organisation. “But her lowest time was when she wasn’t [there]. She was virtually living on the streets for a while. […] She turned up to help years later. Her mother […] was incredibly impressed with her. […] Maybe all those experiences have given her real empathy. She really has turned a corner and is a very pleasant young woman […] training to be a social worker”, stated Jude.

Constructive relationships

According to the participants, structured activities could promote collaboration, constructive role-modelling, strong friendships, autonomy and reduction in antisocial behaviours. Teamwork was considered important by Jude because, “we all do our best if we cooperate rather than be in competition.” Cooperation was promoted by encouraging youth to play without winners and losers, learning to negotiate and compromise. “If you have never had socialisation and responsibility to a group you won’t [compromise] because the child is so strong in you”, explained social worker Sam.

Many professionals reported young people learned to consider and help others through engagement in structured activities. 14 year old Ann spent “so much time thinking about her own problems, things that she didn’t like […]”, remembered Jude. When they went on a camping trip overseas “everybody was ill [and] I expected her to be one of the worst, but […] she actually rose to the occasion.” She helped the children “who were really rough. […] Seeing somebody in a worse situation helped her to see that she had to think about them. […] I saw a side to her that I hadn’t seen anywhere else.”

Sometimes helping others involved becoming a role model of how to behave, being caring and helpful. “The younger ones knew they could rely on this older girl who was there to help to look after them’, recalled school teacher Ruth. Social worker Sam reflected that supporting others allowed children to learn that everybody has different strengths. She recounted how a 12 year old boy was teaching her roller-skating. “I was petrified – ‘I’m going to fall, break my neck!’ And he would say, ‘you won’t fall’. There was roundness in the relationship – it was not just about us teaching them.”

A few participants emphasised that activities helped to establish strong friendships that continued years after they left the youth organisations. Jude remembered Simon had “a massive head injury” as a result of a serious car accident. When his friends from the Sparkle went to see him, “he realised who they were and went to speak to them. His father was almost in tears because it was the first indication that his mind was working properly.” Simon made “a remarkable recovery” and his friends from the Sparkle “have been supporting him during all this time.”

Therapeutic support

Most professionals acknowledged that they played a central role in ensuring the activities were enjoyable and successful. SENCO Jude’s experience suggests that the role of the facilitator is to ensure that activities are fun. “It’s got to remain fun. If it doesn’t, then you quickly adapt the rules or move on to a different game. You don’t want to knock their confidence. You need to be vigilant.”

Professionals reported they nurtured youth’s resilience through role-modelling, encouragement, feedback and guidance within a safe space. Jude knew Peter was able to dance hip-hop, and so consistently encouraged and supported him to run a session for the younger ones. “I think he felt very pleased with himself afterwards.” With Jude’s guidance Peter was able to encourage a boy with learning difficulties who already knew some hip-hop. “It’s the sort of double-edged success. It’s a lot to do with giving opportunities, but then support to make sure that it does work.” By contrast, according to family therapist Matt and social worker Sam, some unstructured activities with peers could promote antisocial behaviours and maladaptive coping strategies.

Helping young people to reflect on their experience was an important part of the process. Family therapist Matt enabled Paul and his family to share their experience of bereavement exploring helpful strategies in supporting each other. While Eva was supported to explore “the other person’s point of view”, according to primary school teacher Ruth.

Social Policy and Service-level change

Some participants reflected that the integration of services, including working with families as a whole can help to sustain resilience outcomes, and considered they had witnessed improvements in this over time. According to social worker Sam who retired 30 years ago “there weren’t enough communication and togetherness [between the organisation and the parents]. It was quite isolated – we took them out of that sphere and put them in another. Our job was limited to 48 hours”. However, in more recent social worker Pat’s experience, “you are supporting the family so the family can keep the child at the centre. […] Now family social workers, might suggest working with brother and sister together […]. In those days there was nothing like that.”

Continuity of funding of youth organisations was reported to be a significant challenge in both the recent and more distant past. It led to the closure of the Rainbow thirty years ago and elsewhere it was implied that limiting therapy input might have contributed to Sara’s and Luke’s relapses. Matt and Jude reflected that getting government grants, is much more difficult now, and that time-limited interventions, targets and long waiting lists have become more predominant. Matt stated that in mental health services more funding is being directed towards talking therapies, while forty-fifty years ago “activities were all we ever did”. By contrast, social worker Sam believed activity participation has become more valued in school settings.

Some participants considered the sort of resilience-building work they used to do is being challenged by increasing recording on complex computerised systems as part of a drive to evidence accountability. Pat was concerned this can reduce the direct contact of working with children and their families. Sam was apprehensive about the lack of flexibility, increased focus on materialism and negative perceptions regarding being tactile with children. She was among those who expressed a relief they are not part of the current system.


A range of different activity types were reported, often closely aligning meditative or cognitive approaches, and those based more on activity itself. Retired professionals’ descriptions of the impact activity participation had on young people facing a range of adversities revealed commonalities. Structured activities promoted competence, confidence, self-esteem, self-awareness, roles, routines, responsibility and constructive relationships as was also found by Hart et al (2007), Jessup et al (2010) and Scholl et al (2004). Sometimes this translated into long-lasting friendships, better learning outcomes and future achievements supporting the findings of DeLuca et al (2010) and Woodier (2011).

The extent to which resilience was achieved varied and appears to have depended on a number of factors. Successful outcomes were linked to positive emotional experience. This elaborates upon some findings in previous studies that have made more limited reference to role of positive emotions in building resilience through activity participation (DeLuca et al 2010, Jessup et al 2010, and Woodier 2011). More broadly, positive emotions have been proposed to be an underlying mechanism for resilient adaptation, associated with resistance to and recovery from stressful life events (Ong et al 2010). Thus some of the successful transitions undertaken by young people may have been aided by positive emotions experienced during the activities which participants described.

When enjoyment is the main reason for pursuing an activity and the level of challenge matches the existing skills, flow or optimal positive experience can occur (Csikszentmihalyi 2002). Such deep and sustained immersion in the activity can contribute to opening up to new opportunities emphasised also in resilience research (Ungar et al 2005), potentially leading to a turning point in a young person’s life. Positive emotions are also related to feeling calm, safe, connected and trust in others (Csikszentmihalyi 2002), which may have further contributed to successful resilience outcomes of the kind reported by our participants.

Because children and youth naturally enjoy play (S Bazyk and J Bazyk 2009), experience of flow may be a significant mechanism in their engagement and resilience. According to flow theory, pursuing the optimal experience is the main motivation, while skills naturally develop as the level of challenge required to enter flow gradually increases (Csikszentmihalyi 2002). Yet, rather than reflecting on the direct impact of the experience of doing, many of the participating professionals emphasised the way in which activities helped people develop transferable social, educational and life skills as was also the case with studies discussed in the literature review (DeLuca et al 2010, Grunstein and Nutbeam 2007, Hart et al 2007, Jessup et al 2010, Peck et al 2008, Scholl et al 2004, Woodier 2011).

Given that enjoyment may be central in promoting positive experience and success, a good knowledge of how to nourish such experience would seem to be important for those using activities to support young people. There was some suggestion this was more challenging when young people presented with disabilities that professionals were less familiar with. Despite Csikszentmihalyi’s (2002) indication that matching challenges and skills is a vital component of achieving flow (2002), and suggestions that it may also promote resilience (Scholl et al 2004, Ungar et al 2005, DeLuca et al 2010), there was limited discussion by the professionals interviewed in this study of the importance of adapting activities, and increasing the level of challenge. That is not to say that participants did not use strategies of adaptation and grading that are familiar to occupational therapists (Creek 2010) – rather, it may be that the participants’ professional backgrounds provided them with lenses which drew attention to other areas and a language which is better able to express them rather than occupational factors. Similarly, whilst there was little evidence of using goal setting strategies (Dawes and Larson 2010), professionals showed their expertise in rule-setting, fostering collaboration and debriefing – helping youth to consider more constructive stories about themselves and others around them. This was also recognised to be important by DeLuca et al (2010), Jessup et al (2010) and Woodier (2011).

While flow involves a deep level of enjoyment with the awareness of time and space drifting into the background, mindfulness-based activities, also highlighted in the findings, entail conscious awareness of whatever arises in one’s physical, emotional and social being, including unpleasant experience (Reid 2011). In some cases the state of mindfulness and flow may merge and more research is required to examine this. Nevertheless, the findings support Rempel’s (2012) literature review which identified an association between mindfulness and pursing positive experience, reducing problem behaviours and promoting desired outcomes. Similarly, Schonert-Reichl and Lawlor’s (2010) high quality quasi-experimental study found mindfulness can significantly increase positive emotions, social and emotional competence, particularly optimism, self-awareness, attention and concentration, in turn improving classroom learning and resilience. While their finding is consistent with the current study, Sara’s relapse suggests that following up mindfulness interventions is important.

Retired practitioners in the current study suggested that addressing a young person’s capacity to cope with adversity on an individual basis alone may not be sufficient to sustain resilience – a point advanced by resilience researchers such as (Hart et al 2007) and Ungar (2009). Many young people had a history consistent with Wilcock and Hocking’s (2014) definition of occupational deprivation involving limited opportunities to engage in meaningful occupations due to the lack of resources, poverty and fragmented families. In this context maladaptive coping strategies became attractive alternatives to meet their physical and psycho-social needs (Caldwell and Smith 2013, S Bazyk and J Bazyk 2009). The UK government is targeting child poverty (HM Government 2014), however, the proposed strategy has been critiqued as insufficient in the context of widening inequalities and more comprehensive resources, child protection and wellbeing approaches are required (Kids Company 2014).


The interpretation of data was influenced by the researcher’s unique life experience and could be interpreted differently by other researchers. Multiple factors contribute to resilience, and this study highlighted the contribution of activity participation and only from the professionals’ perspectives. Young people’s experiences might have been different and future studies could gather data from both parties. Memory bias is also possible and further research could include interviewing current professionals. Recruiting occupational therapists could provide a comparative analysis of how that profession’s use of activities across services has changed over time. Definite conclusions are difficult to draw from the study due to the heterogeneity of the professionals’ and youth backgrounds, activities, services and points in history.

Implications for practice

Structured enjoyable activities can be significant in promoting resilience. The practitioners in the current study made valuable contributions that have clear relevance to occupational therapists and other people working with children and young people in adverse circumstances. This includes nurturing the experience of fun, mindfulness applications, family-centred practice, debriefing strategies, promoting collaboration, creative interventions, and considering longer-term impact of participation in activities on young people’s resilience. Analysis also suggest there are opportunities in this area of practice for occupational therapists to offer their knowledge of a broad range of disabilities and associated functional impact, and their expertise in individualised goal setting and activity grading.


Analysis suggests that key mechanisms through which participation in structured activities promoted resilience for the young people were: promoting positive emotional experiences and expression; developing routines, responsibility and roles; alongside this, the presence of opportunities for constructive relationships and therapeutic support were important contextual factors. Participants noticed a number of changes over time to policy and service provision. Increased integration of services were judged to have improved efforts at resilience building, whilst concerns were expressed with regard to funding constraints and that administrative monitoring of professionals’ work provided less time for active engagement with youth. Analysis also identified opportunities for occupational therapists and occupational perspectives to make a greater contribution to supporting young people in adversity.

Key findings:

  • Enjoyable structured activities can promote youths’ resilience
  • Key mechanisms were: promoting positive emotional experiences and expression; developing routines, responsibility and roles; enabling constructive relationships and providing therapeutic support

What the study has added:

Increased understanding of how participation in structured activities can build young people’s resilience. More broadly the study has helped establish the relevance of occupational perspectives to resilience research and practice.


The authors thank: firstly, the participants for sharing their rich experiences; and secondly, Professor Angie Hart and other members of the Boing-Boing Resilience Research and Practice network and collaborators in the Connected Communities Imagine project for advice and inspiration.

Kristina Usaite, Occupational Therapist, Sussex Partnership NHS Foundation Trust; University of Brighton and Dr Josh Cameron, Principal Lecturer, School of Health Sciences, University of Brighton.

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Editorial – Issue 2

Welcome to the 2nd edition of the Brighton Journal of Research in Health Sciences (BJRHSc). You may notice a slight change to the name of the Journal. This local branding was done on the basis of discussions with our university Marketing and Communications advisors, because of the existence of several journals that already had the generic title.

The new edublog platform for this edition has several advantages over the more traditional format of the 1st edition of the Journal, and we gratefully acknowledge the help and advice of Nikki Marshall and Mark Higginson from Marketing and Communications who helped us make the shift. I would also like to thank David Bauckham and Simon Whiffin for the time that they have spent customising the site so that it supports the Journal’s needs.

The new platform allows readers to access previous editions of the Journal as well as the current one. Readers can also engage in academic debate on issues raised in all articles through the use of comments facility at the bottom of each (note that all comments will be moderated by the editorial team before they appear). Articles can be shared via a number of social media platforms such as Twitter and Google+, and the platform allows for media such as YouTube clips to be embedded. The content of the site will be indexed by Google and other search engines. Finally, all readers can subscribe to the Journal by email and will be alerted when any new content is published.

This second edition contains information on the SHS Seminar Programme, and contemporary and hopefully very interesting material from contributors. Nik Holland, a current mental health nursing student, makes a novel contribution to issue of the relationship between academic linguistic elitism and the nurse-patient divide. The separate mission statement, co-written with his fellow students, Zoe Hughes, Robyn-Jayne Crofton, Laura Johnstone, Chantelle Maduemezia, Sasha Marshall, Imogen Sotos-Castello and Graeme Wetherill, emerges from their relatively recently constituted Seeking Sense in Mental Health (SSiMH) student collective. As a group, SSiMH aims to create a helpful praxis forum to unite all who are interested or involved in mental health, service user groups and mental health-related organisations. It is refreshing to see such a level of engagement among nursing students, in times characterised by an urgent need for such examples of critically reflexive initiatives in nurse education, so very good luck SSiMH!

The article by Dr Tania McIntosh provides fascinating historical insights into the changing nature of relationships between midwives, the women they worked with, and the medical profession in urban England from the 1960s to the 1990s. Tania argues that the consumer movement in maternity that developed from the 1960s onwards impacted significantly on policy makers. It also contributed to the shape of a radical agenda for midwives, while constituting a threat to the sense of professional identity and confidence for some in this profession.

On the basis of her engagement in the University of Brighton’s Work, Write, Live creative writing courses, Helen Stanley has produced a very engaging short story in The Other Woman. There is a growing recognition of the utility of such stories as learning, transformational and research tools in the health, social and human sciences, and this is evidenced in the emerging Health Humanities paradigm. In this paradigm context, informed by narrative methodology, David Bauckham’s Love Not Money… article fuses leisure, health, wellbeing and community engagement with the existential meaning and significance of occupation through volunteering at non-League football clubs.

Community engagement is described as a vital component of higher education in both the University of Brighton’s current and emerging Strategic Plans. It is therefore relevant and timely to welcome the article co-written by Warren Stewart, Laura Brown and Sam Harris. This article reports of the evaluation of the impact of the experience of second year student nurses who, as part of optional module work, volunteered to engage with socially excluded groups of children and young people. The article speaks to the ways in which new skills can be imported into undergraduate nursing curricula, and to how the students’ experiences can be interpreted on the basis of educational and communication theory.

Such recognition of student contribution to pedagogy is also a vital part of our current and future strategic direction, and so it with pleasure that we have included Nicola Gentles’ article on the relevance of the Research Process in Nursing. This critical analysis of a research paper was originally submitted as her assignment for the research module, NI502 – Appreciating the Research Process in Nursing.

The new Strategic Plan emphasizes the importance of teaching informed by ongoing local, as well as national and international, research. The vital relationship between occupation and wellbeing and health is fundamental to teaching informed by the occupational science paradigm. In this context, the MSc research paper by Cathy White, a recent Occupational Therapy postgraduate student, and her tutor Dr Josh Cameron is a fascinating critical discourse analysis of the ways in which both occupational therapy and occupations have been represented in the medical media.

The Camtasia powerpoint, From lived experience to poststructural voice: Some implications for the use of autoethnography in mental health research was originally delivered to Masters in Social Work students at the University of Utah in January of this year. As an editorial and production team, we decided to include the link to it in the 2nd edition for two reasons. First, I hope that my development of this critique of some fundamental assumptions in mainstream qualitative research, and how this has informed my own research, writing and teaching, will be of interest to all readers involved in qualitative research.

The second reason is to pave the way for space in the Journal for Camtasia powerpoint teaching contributions. Camtasia powerpoint delivery is now of our time, arguably giving added value to pedagogy, the student experience, and the continuing professional development of academics.

We would therefore like to invite all lecturer readers, and relevant others, to submit their own Camtasia powerpoints for inclusion in the journal.

On behalf of the editorial and production team, we very much hope that you enjoy and are helped by the 2nd edition of the Brighton Journal of Research in Health Sciences, and we look forward to receiving your comments and contributions!

 Dr Alec Grant

Reader in Narrative Mental Health

Lead Editor, Brighton Journal of Research in Health Sciences

School of Health Sciences



A Critical Discourse Analysis of representations of occupational therapy and occupations in medical media.


Introduction:  English healthcare reforms have prompted occupational therapists to increase efforts to promote their profession to service commissioners (many of whom are general practitioners). Concerns exist that some medical doctors may not fully understand the role of occupational therapists. This research investigated portrayals of occupational therapy and occupations in media aimed at general practitioners.

Method: A critical discourse analysis of 13 on-line and 13 magazine articles from a leading medical publisher.

Findings: Two major discourses were identified: occupational therapy is a valued service – this was qualified by 2 articles considering responses to public spending austerity measures; secondly, occupation is an important aspect of life that can be enabled by medication or restricted by illness – this contrasted to very limited presentation of the therapeutic potential of occupations.  Across all findings there was little reference to mental health conditions.

Conclusion: Occupational therapists should welcome acknowledgements of the importance of occupations to people’s health and well-being, and, also the portrayal of occupational therapy as valuable.  However, occupational therapists should increase their efforts to explain the following to general practitioners and commissioners: their effectiveness; how occupations can be therapeutic; and the role of the profession supporting people with mental health problems.


Following a tumultuous journey involving heated debate and last minute amendments, The Health and Social Care Act was passed into English law on March 27th 2012. Thus England underwent the most significant reform of the NHS since its creation in 1948 (Cairns 2012). Key to the reforms is the concept of ‘commissioning’. General practitioners (GPs) and other health professionals now lead local clinical commissioning groups, choosing what health services they wish to purchase, taking control of 80% of the NHS budget (Charlesworth and Smith 2011). In light of these reforms, various healthcare professional bodies are encouraging their members to promote their role within health and social care and influence commissioners. For instance, the British Association of Occupational Therapists (BAOT) has advised its members that; “by influencing their [commissioners’] decisions you can ensure service users have increased access to occupational therapy services. You can also ensure increased allocation of resources to occupational therapy and more job opportunities for the profession” (BAOT 2011).

Alongside this are concerns that some medical doctors do not understand the occupational therapist’s role (Pemberton 2008, Taylor 2011) – a phenomenon directly observed by the first author whilst a student on practice placements. Previously, Finlay (2004) suggested that ambiguity and confusion about the role of occupational therapists led the profession to a “state of crisis”.  The research presented in this article investigates current representations of occupational therapy by examining how the profession is portrayed in articles on the Pulse Today Website ( for GPs and explores whether or not a relationship between health and occupation is portrayed in Pulse magazine. It is hoped that the findings will be of use to: those tasked with the promotion of the occupational therapy profession; to other professions facing similar challenges; and to researchers interested in the use of Critical Discourse Analysis (Van Dijk 2011).

Literature review

Research related to this topic is dated. Similar studies have not been conducted since the 1990s, when GP fundholding, a very similar structure to the current reforms, was introduced (but not fully implemented). Three studies used questionnaire research to obtain doctors’ perceptions of occupational therapy.  Chakravorty (1993) found that awareness in respect of occupational therapy services was lacking in 50% of GPs and 70% of consultants in a then District Health Authority.  GPs in Greenhill’s (1994) were unaware of the varying roles of occupational therapists and were, as a result, unable to identify the benefits of an occupational therapy service. Similarly, Darch (1995) reported that none of the 22 GPs who responded were aware of the full range of occupational therapy skills as defined by the College of Occupational Therapists.  In all three studies, sample sizes were small, and, as their methods/research questions differed, direct comparisons cannot be made. Recommendations were made on marketing occupational therapy services to GPs such as: maintaining regular contact with updates of new, relevant information; lunch time talks; seminars and/or lectures; and presentations/visits to occupational therapy departments for GP trainees (Chakravorty 1993, Greenhill 1994, Darch 1995). The length of time since these studies were completed and the different policy context suggests the need for new research in this area.

More recently Canadian research, using a multiple case study design, found that understanding of the occupational therapists’ role was essential to support effective integration of the profession into primary care but also that physicians’ (GPs) had a lower level of this understanding than other disciplines (Donnelly et al 2013).  Studies investigating other professionals’ perceptions of occupational therapy has been carried out. For instance, Pottebaum and Svinarich (2005) used survey research as a method to capture psychiatrists’ perceptions of occupational therapy, and compared this information with the number of referrals they make. They found that the psychiatrists with least knowledge of the role of the occupational therapist were less likely to refer people to them.

Taylor (2007) typified research on how members of the multi-disciplinary team view the role of occupational therapists as “well worn [and] of little value to a wider audience” (p6). Similarly, in a letter to The British Journal of Occupational Therapy, Creek (2000) recommended that occupational therapists stop worrying about other professions not understanding their role, and “accept that it cannot be encapsulated in a few words” (p405).  Finlay (2004) and Fortune (2000) were amongst those who disagreed, calling for further research in this area.  It remains the case that published literature on the subject is dated and lacks in methodological diversity. Above all the changed social and political context in the UK and internationally supports the need to explore the complex processes involved in the representations and understandings of the role and practice of occupational therapists amongst other professionals (Reeves et al 2010).

The limited recent literature examining general practitioners’ perceptions of occupational therapy, coupled with the major role GPs are set to take in determining the future of healthcare in England, suggests a need for more research into this topic.  Accordingly, this article reports on a study which aimed to answer the following research question:

How are occupational therapy and the link between health and occupation portrayed to general practitioners?


Critical discourse analysis (CDA) is used by many researchers to understand the social and political influence of text or talk (Van Dijk 2011).   CDA not only analyses text (which may be words or pictures), it also theorises on the social and cultural contexts in which texts are produced and interpreted. Since these contexts were considered central to answering the research question CDA was selected as a suitable methodology for this study.

The focus on power in CDA has been developed by the key foundational social theorists (such as Chouliaraki and Fairclough 1999), who have been particularly interested in the ways discourse practices reproduce and/or transform societal power relationships (Lillis and McKinney 2003). Lo-Bartolo and Sheahan (2009) used CDA from an occupational science perspective to analyse an Australian government newspaper promoting employment reforms. Their study makes full use of CDA’s ability to interpret power relationships between groups, claiming “power is the bridging concept between the seemingly unrelated topics of industrial relationships and occupational science” (p410). Other authors use the principles of CDA to explore discourses in texts but do not address power issues to the same extent. Pattison (2006) acknowledges that discourses identified in key UK critical care documents include the power dynamic between professions, families and patients. However, she also explores other discourses such as how the technological environment can act as a barrier to good end-of-life care.

Central to the CDA approach is to acknowledge and make transparent the position of the researcher. One charge levelled at discourse analysis is that researchers read what they want to find in the texts they analyse (Smith 2006). Reflexivity is defined by Green and Thorogood (2009) as “the process of reflecting on both your own effect on the data generated as a participant in the field, and on the social and cultural processes on the research itself” (p286). These authors go on to say that reflexivity is “essential in qualitative research” (p 286). The current study used reflexivity in conjunction with a consistent methodological approach to address Smith’s (2006) critique and to increase reliability.  A critical approach starts from a certain stance; here this was related to the first author’s role as a student occupational therapist at the time of conducting a MSc research project and her first-hand experience of the discourses between the groups being studied. It is acknowledged that this background influenced the reading, understanding and interpretation of the texts under analysis.


Critical discourse analysis “behoves researchers to explain their own analytic methods” (Annandale and Hammarstrom 2010, p574). To aid this, studies within health and social care literature that used principles of discourse analysis as a methodological approach were reviewed. This exercise guided the selection of specific methods detailed below.

Data source selection

According to Corcoran (2005) media plays a “historically unprecedented role in dominating the symbolic ecology of modern life” (pxii). Bell and Garret (1998) consider media to have “a pivotal role as discourse bearing institutions” (p5). Thus, media texts are frequently the subject of analysis for researchers carrying out discourse analysis because of the power exerted on their audiences (Smith 2006). Media texts therefore offer a sound source of data for investigation of how a topic is portrayed to audiences.

Pulse on-line and Pulse magazine were identified as potential data sources because of their wide reach to their target audience of general practitioners. Further details about these sources and the reasons for their choice are provided in the results section below as this forms part of the sociocultural and discourse practice levels of analysis. There were two research elements; one focusing on portrayals of occupational therapy, and the second on representations of the link between occupation and health. Both elements used Fairclough’s (1995) three tier approach to critical discourse analysis, which was deployed as the first stage of analysis (Fig. 1).

Fig.1: Stage 1: Fairclough’s three-tier approach to discourse analysis

medicalMedia1After completing this stage, the analysis took two separate directions for each research element. Research element 1 (RE1), focusing on representations of occupational therapy, considered 13 online articles from Pulse online that contained search term

“occupational therapy”.

The method of analysis is outlined in figure 2.

Fig. 2. RE1- Approach to analysis of online articles’ representations of occupational therapy

medicalMedia2Research element 2 (RE2), focusing on portrayals of relationships between occupation and health, analysed content from Pulse magazine for GPs. Three editions were selected from six months’ of issues immediately preceding the commencement of this stage of the study in order to provide up-to-date data. These editions were selected randomly using an internet based random number generator designed specifically for researchers (Urbaniak and Plous 2011).

Those that were selected were from Volume 72 (2012);

  • Issue 3
  • Issue 9
  • Issue 11

The first author carefully read each of these issues.  Approaches from occupational therapy were used to support analysis. Several occupational therapy models divide human occupation into the three domains of productivity, leisure and self-care all within the context of a person’s environment (see: Townsend and Polatajko 2007; Baum and Christiansen 2005; Kielhofner 2008). These three components of human occupation were used as a framework when searching for articles related to human occupation.  Articles that made reference to at least one of the three domains of human occupation, or to the environmental context of patients’/clients’ lives were included for analysis.

The selected articles were presented to the second author (the first author’s research supervisor) for discussion before conclusions were drawn. In this way the second author adopted the role of a “critical friend”, which is common practice in discourse analysis (Pattison 2006, Nyman et al 2011), by pointing out other possible interpretations and discussing those that had been identified, therefore adding to the reliability of the data.  See figure 3 for an overview of the process taken in this research element.

Fig. 3.  Approach to analysis of magazine articles’ representations of relationships between occupation and health

Results and discussions

Results from both research elements are presented and discussed below using the format of Fairclough’s (1995) three levels of critical discourse analysis: sociocultural; discourse practice and text analysis (to which greatest emphasis is given) (see Fig 1.)

Sociocultural level of analysis
Pulse magazine’s listing on online journal database host EBSCO lists the publication’s subject areas as a) health and medicine and b) politics and government. Discourse in Pulse publications was largely dominated by political issues, such as the health reforms in England, in which GPs hold a central role, and the hotly contested pension reforms for doctors, over which both hospital doctors and GPs were considering industrial action at the time of writing.

The socio-cultural environment in which these publications were produced was one of political turmoil. The reforms of the NHS have been understood as an attempt to curb the costs of running the health service (BBC 2012). They were produced during a global financial crisis, resulting in recession the UK and much of Europe and consequent austerity measures. To a degree, the publications selected for analysis reflected that heated political environment. Political issues dominated the headlines and draw the reader into the magazine or website using bold political statements and images. See figure 4 for examples.

Fig. 4- Pulse magazine headlines

medicalMedia4 In the Royal College of General Practitioners Chairman’s report for 2010-2011, the dominance of political discourse among GPs was acknowledged, “when I stood for Chair of Council I didn’t for one moment expect that my first year of office would be dominated so heavily by the Health and Social Care Bill” (Gerada 2011, p2). However, a deeper investigation into media and publications aimed at general practitioners suggests that the fundamentals of general practice – most salient being patient care – remain the primary concern. Gerada’s report (2011) highlighted many key issues the College continued to work on, such as promoting healthy living and supporting people with mental health issues. Beyond the headlines, both Pulse magazines and website devote a significant number of column inches to articles on clinical topics such as case studies, training and other patient-related issues.The research reported in the current study focuses on portrayals of occupational therapy and the link between health and occupation within media sources aimed at GPs. It is discourses relating to this primary focus of general practitioners, patient care, that are of interest. However the wider socio-cultural context of these discourses cannot be ignored as they influence and may help explain their significance and potential impact.

Discourse practice level of analysis

The texts under analysis were targeted at General Practitioners working in the UK. After careful consideration of several publications, Pulse was identified as an appropriate media source to draw upon for this research.
The Pulse Today website and Pulse magazine are both owned by UBM Medica. Pulse’s marketing uses the slogan- “at the heart of general practice since 1960” (UBM Medica 2012), suggesting that it is respected and has a wide reach. Accessing information about traffic on the Pulse website is difficult- with only vague details such as “traffic has tripled over the last couple of years” revealed in Pulse’s media pack (UBM Medica 2011). Detail about the distribution of the magazine is readily available- 35,000 copies are distributed weekly (UBM Medica 2011) and a UK-wide medical readership survey conducted in 2011, placed readership of Pulse ahead of its rival, GP magazine, claiming that 88% of GPs have read Pulse at some point over the last year (Hoey 2011).  The powerful position Pulse holds in the area of media aimed at primary care professionals is demonstrated by the significant number of stories picked up by national news agencies that first appeared in Pulse or on the website. This was the case for an average of one story per week over the past two years (UBM Medica 2012).

Textual level of analysis

The analysis identified two dominant discourses which are presented and discussed in relation to wider literature below. Also included in the discussion are some important qualifications to these discourses and a consideration of the very limited mental health related content in the texts.

Discourse 1: Occupational therapy is valued by general practitioners

Occupational therapy was almost universally constituted in the texts under analysis in RE1 as a valuable service (and also in one of the RE2 articles). This discourse emerged in the context of the following patient groups/settings:

  • Rheumatology
  • Complex regional pain syndrome
  • Housing
  • Multiple sclerosis
  • Parkinson’s disease
  • Musculoskeletal conditions
  • Falls (RE2)

Most articles referred to occupational therapy in the context of a valued member of the multi-disciplinary team – for instance:

“The management of RA [rheumatoid arthritis] is a lesson in the value of the multidisciplinary team. It is critical that patients have access to physiotherapy, occupational therapy, podiatry, social and psychological support….”

Article 3, RE1.
Another theme identified in RE1 which supported the discourse – was: Occupational therapists can provide beneficial non-drug therapies
This theme emerged in the context of the following patient groups:

  • Alzheimer’s disease
  • Pain in elderly people

For instance:

“The benefits of treating pain are manifold […]. However, older patients may view analgesia with suspicion and take it reluctantly, and the use of non-drug therapies, including physiotherapy, occupational therapy, massage therapy and psychological therapy, should be considered”

Article 8, RE1.

The themes identified here, which have all been categorised under “discourse 1”, emerged from over 92% (n=12) of the articles under analysis in RE1. All of the articles from which this positive portrayal of occupational therapy emerged were written by doctors from various disciplines working in both acute and primary care settings. The significance of this will become more apparent to the reader in later discussions examining discourses that emerged from advertisements, which have distinctly different origins.

These are promising findings for those tasked with the promotion of the profession. They contrast to past findings low levels of medical doctors’ understanding occupational therapy (Chakravorty 1993, Greenhill 1994, Darch 1995, Pottebaum and Svinarich 2005), Though direct comparisons cannot be made because these studies were surveys of medical practitioners whereas the current study gives an insight into knowledge of those doctors who write on Pulse’s website, it is notable that in RE1, 38% of the authors were consultants and 62% were general practitioners. The discourse identified suggests that there are influential GPs and hospital consultants who may now value occupational therapy to a greater extent than in the past, and as a result portray the profession in a positive light when authoring work that is aimed at GPs.

The positive evaluation of occupational therapy was qualified by two articles in RE1 included in a theme of service provision in financial austerity.  In the satirical article 11, a GP laments the fact that her patients cannot access an occupational therapy service because it has been cut. Without the same sentiment of regret at the loss of service provision, in article 10, Dr. Shane Gordon suggests that commissioners become more creative with their spending, replacing occupational therapists with self-assessment tools:

“Your local authority may be a willing partner in changing models of care provision – remember local government has a 15-year headstart in how to commission services…..They may also hold information to help residents access resources directly, which could equally be accessed through your surgery. This could even include sophisticated tools such as self-assessment for home equipment, traditionally provided through occupational therapy services. This in turn can provide more rapid access to equipment, prevent unnecessary admissions to hospital and maintain the patient’s independence.”

Article 10, RE1
In this time of national financial austerity, and with the NHS reforms handing over control of the purse strings to the target audience of these articles, this theme provides a stark reminder to occupational therapists of the need for GPs to understand their role and value their services. To an extent this theme conveys the same resounding message – that occupational therapy services are valuable in preventing unnecessary admissions and promoting independence. The value placed on occupational therapists however, is different in the second article, as there is an assumption that assessing the home environment does not require the active use of an occupational therapist’s knowledge base or specialist clinical skillset.

Discourse 2: Human occupation from the medical model – Illness restricts, medication enables occupations

Many of the advertisements in Pulse magazine analysed in RE2 displayed clear occupational images – nowhere was a more salient link between health and occupation identified. Advertisements made up 62% of the texts analysed in RE2, and within these 75% revealed two dominant themes:

  1. Illness restricts occupation: examples include an image of a man unable to go outside and join friends who are eating a meal in the garden because of post herpetic neuralgia
  2. Medication enables occupation: examples include an image of couple ballroom dancing enabled by anti-inflammatory medication; and the example in Figure 5 below.
Fig. 5:  Text 12, RE2. Example of advertisement with clear occupational image- medication enables occupation. (Component of human occupation referenced- play).

medicalMedia5According to Wilcock (2005), “occupational therapists are widely associated with a medical model of healthcare in which recognition of how engagement in occupation contributes to health status is poorly understood” (p5). Wilcock goes on to note that she does not condemn the medical model but acknowledges that it’s approach to health differs from that of occupational therapy suggesting that occupational therapists have much to offer medicine. Advertisements for medication are useful sources of information regarding the kinds of ideas and representations about health and illness that are held and promoted within sections of the health industry, whether intended, or implicitly perpetuated using text or images (Foster 2010). The discourses identified portrayed a distinct link between health and occupation, but very much from within the confines of a medical model – occupation is seen as a central part of a person’s life which can either be restricted by illness or enabled by medication. Occupational science as the study of people as occupational beings takes a different approach to this link – that occupation itself can be therapeutic and health giving (Wilcock 2005). The discourses identified rarely portrayed occupation as something that can be therapeutic.

The analysed advertisements were produced by global pharmaceutical companies with multi-billion dollar annual turnover (Davidson and Greblov 2005). Within this specialised industry, significant resources are invested into marketing in order to maximise the potentially very-high profits that can be secured from developing and marketing a particular treatment (Kotler et al 2005). Context, therefore, is key. These firms are well-versed in the foundational concepts of marketing- that its aim is to make selling superfluous, it is to know and understand the customer so well that the product or service fits and sells itself (Kotler et al 2005). Foster (2010) cautions that “it would be erroneous to suggest that all professionals that encounter these, and other advertisements for medication […] are passive recipients of the explicit and implicit representations contained within them” (p32). However, the same author goes on to remind analysts not to underestimate the power of advertising methods and the numerous ways in which they influence individuals at conscious and sub-conscious levels.

The under-representation of mental health conditions

The virtual absence of content related to mental health was an unexpected finding; especially given the significance that Gerada (2011) had attached to the issue in primary care referred to above. With one exception (Alzheimer’s disease), all articles and texts that were subject to analysis referred to physical health conditions only, making no mention of mental health conditions, either in the context of the occupational therapy role or in the context of a link between health and occupation. None of the advertisements analysed in RE2 were promoting medication to treat mental health problems.

Foster (2010) had used mixed quantitative and qualitative methods to examine the differences between advertisements for psychiatric and non-psychiatric medication.  That study found that advertisements for non-psychiatric medication were much more likely to contain images of people participating positively in activities of daily living, whereas advertisements for psychiatric medication tended to portray people in abnormal situations, in a negative way.   This suggests that the discourse linking occupation to health and well-being may not have been as dominant had advertisements for psychiatric medication been present.

NHS choices (2012) recommend that the GP is the first point of contact for patients experiencing mental health problems. The BAOT estimates that approximately one quarter of their members work in mental health settings (BAOT 2012). In England, it has been estimated that mental health conditions cost approximately £105 billion a year (Centre for Mental Health 2010), due to loss of earnings and associated treatment and welfare costs. Mental health has therefore been prioritised for economic as well as health related reasons. Considering these facts, the limited content regarding mental health issues has important implications for both the occupational therapist who wishes to remain in valued employment and for the service user. It suggests there may be a lack of consideration of mental health as a whole in media aimed at general practitioners, not just a lack of understanding about the role of occupational therapy in this setting.  It is difficult to accept arguments that the general public should see mental health problems in the same light as any other health problem if mental health issues are not presented to general practitioners alongside other health conditions.

The three previously cited studies that examined GPs’ perceptions of occupational therapy conducted in the 1990s all made similar findings regarding doctors’ and general practitioners’ perceptions about occupational therapy and mental health (Chakravorty 1993, Greenhill 1994, Darch 1995). All found that their general level of awareness about the role of occupational therapists was biased towards physical health. It is possible that the current study’s findings may suggest an enduring knowledge gap in GP’s general awareness of mental health issues and not only regarding the occupational therapy role with this client group. This issue merits further exploration given the estimation that about 30% of GP consultations have a mental health component (Kendrick and Simon 2008).

Implications for promotion of occupational therapy and the profession as a whole

The following implications for occupational therapists tasked with the promotion of the profession are suggested from the discourses identified:

          • Occupational therapists should welcome the finding that the profession is valued by general practitioners, especially with regard to physical conditions. Marketers are interested in attitudes and beliefs, as they affect buying behaviour (Kotler et al 2005). Emergent discourses suggest the attitude and beliefs of the target audience provides a solid foundation upon which to build awareness of the benefits of occupational therapy.
          • Promotion of occupational therapy services to GPs should make use of the shared discourse, revealed in this research, that there is a link between heath and occupation. It must also be considered that “cultural factors exert the broadest and deepest influence on consumer behaviour” (Kotler et al 2005, p256). Occupational therapists should be mindful that the target audience views this link from within the medical model and within a distinct socio-cultural environment. Thus occupational therapists should endeavour to explain and evidence ways in which participation in occupations can be therapeutic in themselves and not only the outcome of other interventions.
          • Occupational therapists and other professions should note that as GP led commissioning takes hold, they will be challenged to demonstrate the cost-effectiveness of their services, and that GPs may consider alternatives. A recent promotional leaflet produced by the BAOT (See fig. 6) lists the NHS priorities occupational therapy can assist GPs to meet, however the socio-cultural level of analysis suggested that saving money is the fundamental NHS priority underpinning the health reforms, and though implied, this is not mentioned in the leaflet. Occupational therapists may need to present information about the efficiency of their services in a more explicit manner whilst also warning of the dangers of false economies and negative health consequences of failing to use the profession’s skills and expertise.
          • There appears a pressing need for occupational therapists to promote their potential role in the area of mental health to general practitioners. The very limited content of information in the texts analysed (and in additional texts in the magazines) related to mental health issues point towards a wider debate than is beyond the scope of this article. What can be implied is the need for occupational therapists to promote the fact that their training enables them to provide therapy for people with mental health problems as well as physical health conditions. The flexibility of occupational therapists should be promoted so that their full skill set can be utilised and valued.
Fig. 6 College of Occupational Therapists promotional leaflet


Limitations of the study and future research

There are a number of important limitations to this study that also suggest directions for future research.

It needs to be stressed again that this study explored representations of occupational therapy and occupations in media aimed at general practitioners.  Whilst this may influence and have some relationship to the actual views of GPs further study is needed to explicitly gather GP’s views and perspectives.  It should also be acknowledged that this study drew on material from one publisher – albeit a leading one in the field that included much material written by a broad range of medical doctors.  Further research using material from other publishers or professional bodies could investigate whether the discourses revealed this study are present in other sources.

Comparison of how another profession is portrayed in similar media could be a valuable undertaking for future research. This, combined with a quantitative approach to examining the number of articles that discuss the interventions of other professionals could contribute rich comparative data. The fact that 13 articles in RE1 were written over a four year period did not account for the fact that many more articles did not mention occupational therapy at all. No quantitative analysis (e.g. counting the number of articles written in this period so a percentage of those that made reference to occupational therapy could be calculated) was undertaken.

Time and word count restrictions meant that regrettably, some more minor discourses have not been reported and discussed in this article. E.g. occupation portrayed as a risk to health (article 4, RE2). These more subtle discourses would make for interesting topics of further research.
The very limited content relating to mental health problems prompted an unanticipated discussion. Further research from an occupational perspective in this area would complement work such as Foster’s (2010), and provide relevant and worthwhile data for the profession in seeking to promote its potential to support people with mental health problems.


The most frequent representation of occupational therapy was as a valued service. This finding should be welcomed by occupational therapists tasked with the promotion of the profession – which one could argue is all occupational therapists. Media articles aimed at general practitioners portrayed occupation as an important aspect of human life which could be limited by illness and enabled by medication. Those designing promotional material should also welcome this finding as it acknowledges the importance of occupation to peoples’ lives.  However they should be mindful that this positive relationship between health and occupation was almost universally presented to GPs from within the medical model, and occupation was rarely portrayed as being therapeutic in itself. Thus occupational therapists should continue efforts to explain and develop the evidence for the therapeutic potential of occupations.  There was found to be very limited consideration of mental health issues. Occupational therapists should acknowledge that their role in mental health may be less well understood than their role in a physical setting by the GPs to whom they are promoting their services.
Key messages:

  1. Occupational therapy is portrayed as a valuable service in medical media.
  2. Occupational therapists should aim to develop acknowledgements of links between occupation and health in medical media.

What the study has added: A useful insight using critical discourse analysis into how occupational therapy and occupations are portrayed in media aimed at general practitioners, who are key players in funding healthcare services.

Cathy White MSc Health through Occupation student and Dr. Josh Cameron Senior Lecturer School of Health Sciences

Reference list

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Appreciating the Research Process in Nursing

This essay will provide a critical analysis of ‘Experiences of family carers of older people with mental health problems in the care of acute general hospital: a qualitative study’ (Clissett et al 2013). This article has great relevance to my role as a student paediatric nurse, acknowledging the effects that ill health and the hospital environment can have on, not only the patient, but the family/carers around the patient, demonstrating the importance of family centred care.

On completion of analysis, I will demonstrate my understanding of qualitative research and the processes that are involved when collecting and analysing data. Ethical and legal issues will be considered to establish the quality, strengths and limitations of the article. A framework, developed by Caldwell, Henshaw and Taylor (2005) will be used to support my analysis, allowing me to develop a deeper understanding of the research process and appreciate how research can benefit my practice in the future. The NMC Competencies (2010) state that ​‘All nurses must appreciate the value of evidence in practice, be able to understand and appraise research, apply relevant theory and research findings to their work, and identify areas for further investigation’ (NMC 2010).

Holloway and Wheeler (2010) suggest that qualitative research focuses on society and how people perceive and interpret their own, individual experiences. Using this approach to analyse family/carer experiences, allows the researchers to gather a range of specific, in-depth perspectives, to develop inductive reasoning. However, in order to do this successfully, Holloway and Wheeler (2002) recommend that research should be related to that of the profession of the authors. Based on the title of the article, the credibility of the authors and the expertise they have, regarding health care and the older generation, I believe they are a reliable source in establishing this research.

The abstract, according to Holloway and Wheeler (2010), should provide a brief overview of the aim, background, the methods, a summary of results and their potential to influence practice. This abstract provides just this. The aim provides a clear outline of what the paper sets out to accomplish, which is rationalised and supported by the background information. The background distinguishes the implications for practice and the importance of working with families when caring for patients with cognitive impairment, ensuring they receive the best possible care.

The design and methods chosen by the authors provides an insight into the strategies used to develop the concepts. With the use of semi-structured interviews and Strauss and Corbin’s framework, the reader can expect to discover legitimate experiences from the participants. The findings reflect this by using quotations from the participants. They proposed that family carers either ‘valued the support of hospital staff and services, or were highly critical of the care provided’ (Clissett et al 2013). These opposing experiences entice the audience to continue reading to discover the reasons for the conflicting views. The conclusion then delivers the key elements family carers of cognitively impaired patients respond to in the hospital environment, thus supplying and enhancing knowledge for nurses, improving practice within this specific field.

Holloway and Wheller (2002) highlight the importance of relating research to clinical practice in order to benefit and enhance health professional’s knowledge and competencies. On consideration of the statistics found in the introduction, they prove great significance to clinical practice, considering over half of 70 year olds have cognitive impairment. However, the term cognitive impairment is such a broad term, that it is hard to categorise at what stage their conditions has an impact on practice, the nurse’s role, the patient and the carers.

The terms delirium and dementia have been cited in the introduction, which leaves the study open and flexible to adverse participant involvement, though this contradicts the title, focusing primarily on cognitive impairment. The Alzheimer’s Society (2013) defines cognitive impairment to be a condition that affects an individual’s ability to think, know and remember. Although these symptoms have the same qualities as dementia, cognitive impairment is not severe enough to be classed as dementia, however, they suggest that this condition could advance to such diagnosis. The Royal College of Psychiatrists (2011) describes delirium to affect the mental state of an individual, causing confusion, due to becoming mentally unwell. So although these all affect mental health, cognitive impairment, dementia and delirium are not classified under the same diagnosis, which leaves the reader to feel unsure of the direction of the paper. This uncertainty is portrayed throughout the paper, identified in the background, aim and design.

Streubert and Carpenter (2011) suggest that, in the background, a justification is needed of how and why the chosen subject is of importance to research and practice. The background has provided rationale for the study, with reference to the challenging environment of acute care and acknowledgment of the positive influences family carer’s have on the dementia patient. It recognises that other relevant studies have been completed with regards to family carer experiences in the acute area, none of which have focused on cognitive impairments. With reference to the statistics in the introduction, this research shows significance to health care practice and can be used in conjunction with the existent related literature, which it has aimed to achieve.

 As mentioned previously, the term cognitive impairment is a vague statement, however, using the word ‘explore’ within the aim allows, to an extent, some flexibility. On consideration of the full aim, the main principle is to understand the experiences of individual carers. These experiences cannot be predetermined from the authors, so the aim cannot be truly specific because not every patient is going to be in the exact same situation. However, the design does provide specificity, proposing the research will help professionals ‘understand the world from the perspective of the person with dementia…interpret and evaluate the experience of older people and their carers’ (Clissett et al 2013). Using the word dementia does imply that the focus of the study will be primarily of patients with this disease, which narrows the criteria and spectrum of participants to be involved.

The design indicates that the approach used to develop research was based around ethnography, which is defined by Holloway and Wheeler (2010) to be a way of investigating behaviours and experiences. Triangulation was used to assess the experiences of family carers in hospital. The use of observations and semi structured interviews to individual participants. Flick (2009) encourages this combination when collecting data because it allows researchers to review from different perspectives, deliberating on subjective knowledge and experience, resulting in a detailed analysis, helping to support rigour. However, there is no evidence suggesting that consent has been obtained for the non-participant observations. Green and Thorogood (2009) suggest that gaining consent prior to observational studies can be problematic. Although researchers want to observe participants in a natural environment, they should be informed of the research aims, objectives and contact information should be issued before involvement.

The setting and sample is introduced through reflection of a similar, larger study, which causes the reader to become disengaged with the prominent study. The setting and sample is not explained until the end of the second paragraph. The analysis of the larger study, I feel, is not necessary in this section. If the authors feel it has relevance to their study, I believe it should be mentioned in the background.

During the sampling stage, ethics were considered. Under section 32 of the Mental Capacity Act (2005) they have taken ethical steps to retrieve consent from participants. Section 32 of the mental capacity act (2005) states that if an approved research project is being conducted and the participant lacks capacity to consent, anyone that is involved for caring for the patient or is interested in the patients welfare and is willing to be consulted by the research under the section, can consent. Due to the context of the paper, any carers involved in the process are eligible to consent for themselves and their family member, if they are not competent in doing so. However, cited at the end of the setting and sampling section, it discloses that out of the 34 participants, 15 of them had one or more mental health problems of their own, which poses the question, did they have the capacity to consent?

Holstein and Gubrium (2003) confirm that the interview process shapes the information received for data collection and analysis. The authors have completed the interviews at the participant’s homes. Allowing them to be in their own environment may have resulted in a more in depth, accurate interview because they felt comfortable and in control of the process, making the situation less daunting. However the interviews lasted between 20 minutes and 2 hours which could suggest that some carers were more open and honest about their experience.

The use of semi structured interviews encourages participants to reveal their own personal experiences, yet still enables the researcher to guide the interview in the right direction. The use of grounded theory supports this notion. Grounded theory was used as an approach to interview. Willis (2007) states that grounded theorist initiate the interview process by using general and broad questions. As the interview progresses, the questions then become structured around the individual participant. All of the interviews were audio recorded. Silverman (2003) suggest that the use of tapes allows the researchers to relive the interviews, comprehend the right information, providing in-depth and systematic analysis. However, the interviews were not returned to the participants for checking, which Clissett et al. (2013) provides no rationale for. This could be due to the fact that once the interviewees had time to reflect on their experiences, their perspectives could have changed, affecting the results.

Bradbury-Jones (2007) specifies rigour to determine whether the qualitative research is methodical and thorough, however, focusing too much on the reliability of the data during data collection can deter creativity and development of the study. Holloway and Wheeler (2002) identify that researchers may find it difficult to agree to the validity and trustworthiness of research, which may show reflection in the broad spectrum of agreement in this paper (68-98%). These discrepancies are not due to preconceived, biased opinions of care in the trust, because none of the researchers involved had a clinical role at the hospitals.

A theoretical approach was taken during data analysis. Charmaz (2003) suggest that using the theoretical approach allows grounded theorists to: ‘(i) gain rich data (ii) fill out theoretical categories (iii) discover variations within the theoretical categories, and (iv) define gaps within and between categories’ (Charmaz 2003). Applying this approach to the experiences of carers allows themes to emerge and develop, which are represented in the results.

The word ‘disruption’ was a key theme established in the results. Clissett et al (2013) explained that disruption was chosen because of its varied meaning. However, they contradict themselves by giving a patronising definition of the word, when the term is subjective to each participant. Positive and negative accounts of care and coping strategies were all established in the results, which were supported by quotations from the interviews. Although these provide a greater insight in to the results, they were too long and repetitive.

The non-participant observations were touched upon to support the findings, suggesting that the ‘hospital processes were perceived as disruptive….the department was seen as a chaotic place’ (Clissett et al 2013). The use of the words ‘perceived’ and ‘seen’ demonstrates that the researchers are not just interpreting what the interviewees had said, but they are commenting from an outsider’s perspective.

In the discussion there are again, many references to other studies, which seemed unnecessary. However, some were deemed to be relevant, with reference to the studies that suggest long visitations can affect the health and mood of the carers, which could have contributed to the negative experiences. The overall discussion of the primary study is comprehensive, but I feel the bullet pointed summary, sums up the key points in a clear manner, rather than the main discussion itself.

One significant limitation identified was the lack of participants. They state that data saturation occurred, however I don’t believe with this number, that any sufficient claims can be made. One way of rectifying this could have been to broaden the spectrum for data collection. Only two hospitals were involved, which were within the same trust. If more hospitals were considered around England, then this would have made the sample and results more rigorous. Time lapses and relationships between carers were also a problem when completing the research. However if interviews took place sooner, due to their situation and vulnerability, it may have been viewed as invasive and disrespectful.

The conclusion identifies the key attributes that need to be adopted by nurses in order to improve family centred care. The importance of triadic nursing has been highlighted throughout, recognising the involvement of family carers and how their expertise can be used to benefit the care of the patient. All of the suggestions to improve care are transferable and achievable within practice. I believe the conclusion to be beneficial to all nurses, regardless of the field or area they work in. Communication is fundamental when working with any patient and family, so although this paper has primarily focused on patients with mental health conditions, the findings can be used in every aspect of nursing.

I believe this paper will have an impact on my personal education and practice. As a paediatric nurse, The Nursing and Midwifery Council (2013) state that we should ‘Acknowledge the role of siblings, other family members and friends in the lives of children and young people and the effect that illness or disability may have on them. Work positively with siblings and friends for the benefit of the child/young person’ (NMC 2013). Clissett et al (2013) have produced a paper that is specific for one area; however I believe the results prove to be transferable in all health professions.

Nicola Gentles Adult Nursing BSc (Hons) student


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Charmaz, K. 2003. Inside Interviewing New Lenses, New Concerns. California: Sage Publications, Inc.

Clissett, P. et al. 2013. Experiences of family carers of older people with mental health problems in the care of acute general hospital: a qualitative study. Journal of Advanced Nursing 70 (1): 2707-2716.

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Academic elitism: do universities contribute to the patient-nurse divide?

It could be argued that the historical templates for the academic model were shadowy societies such as the Freemasons or the Pythagorean Brotherhood (Encyclopaedia Britannica, 2015) who considered themselves responsible for the guardianship and careful dissemination of powerful and secret knowledge to trusted initiates. This binary thinking, a division between those who have the knowledge and the ignorant who do not, may be replicated in perceived academic and intellectual divisions between doctors, nurses and service users (Davies, 2003).

The currently dominant biomedical model elevates specialist knowledge (Nettleton, 2006) and an aura of professional infallibility (Obholzer, 2003). It may serve to create a divide between service users and those responsible for their care (Hall, 2013). It may also be a factor in the development of a role divide between nurses and doctors (Ritchie, 2013) based on traditional patriarchal professional medical identity (Davies, 2003). A major challenge to the development of therapeutic patient-practitioner relationships may be the use of technical jargon and acronyms (Beattie, 1994; Charlesworth, 2003; House of Lords, 2000; Naidoo & Wills, 2010; Pyper et al, 2008). The nursing graduate course, heavily reliant on the completion of academic assessment may serve to encourage the use of such complex language, challenging professional boundaries between nurses and doctors but accentuating barriers between nurses and service users.

All nursing is becoming more technical (Stein-Parbury, 2009) with the result that nurses may need increased intellectual resources to integrate the required technical competence with traditional nursing skills (Beasley, 2011). Nursing has only recently become a graduate profession and detractors question the need for increased academic demands for nurses, arguing that this may impact on the care component of the nursing role. There appear to be no such questions, however, over the perceived levels of educational attainment required for doctors (Ritchie, 2013).

The growth of globalisation may present challenges to nurses (Hussein et al, 2011), requiring increased cultural competence to ensure the provision of appropriate, culturally-sensitive care (Gorton & Hall, 2013). Nurses are expected to advocate for patients (MacDonald, 2006) as well as acting as conduits for information between patients and doctors. User movements and the widespread availability of information via the internet are contributing factors in the increasing levels of patient sophistication which may challenge patient-practitioner power imbalances (MacKian, 2010; Florin et al, 2008; Kangasniemi et al, 2010), placing further demands on nurses to be able to engage appropriately with patients, answering questions relating to treatment and supporting patients to make informed choices about the care they expect or are willing to receive.

It appears that there is little question over the need for enhanced levels of educational attainment to allow nurses to fulfil the varied aspects of their role. Technical and cultural competence, the need to act as interpretive intermediary between doctor and patient and an ability to discuss treatment and care with often increasingly sophisticated patients or carers all indicate that the nursing field requires elevated levels of study and training. However, nurses may need to concentrate on finding a balance between the academic language supporting the specialist knowledge required to manage in an increasingly complex workplace and the need to be able to communicate and engage effectively with patients on an inclusive and equal level. Caution may be required to ensure that the linguistic elitism which may be produced by exposure to a graduate program with its focus on academic assessment does not ultimately create barriers between nurses and their patients.

Nik Holland Mental Health Nursing BSc (Hons) student


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From lived experience to poststructural voice: Some implications for the use of autoethnography in mental health research.

Podcast lecture for MSc Social Work students, University of Utah given by Dr. Alec Grant, Reader in Mental Health


Controlling birth? Relationships between midwives, women, and the medical profession in England, 1960-1992.


This paper will explore the changing nature of relationships between midwives and women in urban England between 1960 and 1992, and is part of a larger study on the history of maternity in twentieth century England.   The paper uses interviews with midwives and members of maternity consumer groups, as well as contemporary documents, to argue that two developments over the period had a significant impact on the ability of midwives to relate to the women in their care. Each was seen particularly in urban areas, and was in response to the demands of an urban ‘elite’. The first was the push by specialist obstetricians for the use of hospitals for birth, and for the use of technology for diagnostic and therapeutic purposes. The second was the foundation of consumer groups which focused on the experience of the childbearing woman. Both developments were predicated on the belief that the prevailing system of maternity care was flawed and potentially dangerous, and both sought vigorously to change the experience of pregnant and birthing women. Furthermore, the development of consumer groups, often as a direct result of the perceived impact of the medicalization of birth, eroded the relationship between women and midwives by implying that they were working towards different goals. Evidence suggests that midwives attempted to neutralise, or even come alongside women in these debates. Ultimately, however, the voice of the urban consumer and the medical elite had a decisive impact not only on how midwives came to describe their work but also on the rhetoric and policy of government in the area of maternity services.


In the late 1950s the maternal death rate in England was 3.2/10,000 (dropping to 0.81/1000 by 1990) births and although this was a much improved figure on that of the immediate pre-war period, obstetricians increasingly used the rhetoric of danger when discussing birth (Macfarlane et al 2000). There were a variety of reasons for this; some of them altruistic, some less so. A tripartite system of maternity care in England had been created following the development of the National Health Service in 1948. This meant that general practitioners [GPs], local health authorities (who employed district midwives) and hospital based obstetricians all had involvement in the care of pregnant women. At the same time the birth rate was rising (Macfarlane et al 2000). The conclusions of a Government report looking at the structure of the maternity services in 1959, demonstrates the influence that obstetricians wielded over national policy (Ministry of Health 1959; ‘Cranbrook’ Report). Although the Report defended ‘the advantages of home confinement for the apparently normal case…’ it urged that beds should be available for 70 per cent of women to have hospital births. It also agreed that most GPs did not have the skills to be involved in any aspect of maternity care. In many ways, the Report was just confirming what was already occurring, with an average of 65 percent of births in England already taking place in hospital settings. By 1970 the influential Peel Report, another Government publication, was arguing that enough beds should be available to allow all women to deliver in hospitals, and that all care should be given under the auspices of hospitals, rather than being devolved to local authorities or GPs (Department of Health 1970 ). Again, the recommendation signalled what was already happening, with 81 per cent of all births occurring in hospital in the late 1960s. At no stage was home birth actually outlawed, although the Short Report, came close to this with its argument that childbirth should be seen as analogous to intensive care and should take place in a similar environment (Department of Health 1980). As one consultant put it at the time: ‘A lifetime in obstetrics convinces me that no baby should be born at home unless circumstances prevent hospital admission’ (Davis, The Times, 21.05.1980)

The question of safety was at the heart of many of the debates and much of the rhetoric around birth in the post-War period. The majority of obstetricians believed that there was a direct causal link between hospital births and reduced maternal and perinatal mortality. Alongside the place of birth, the development of technology in pregnancy and birth was seen as a way of reducing the risk of mortality and morbidity (Shorter 1983). This included the use of ultrasound scans for visualising the foetus, sonar waves for amplifying the foetal heart rate, epidurals for pain relief, caesareans and inductions of labour (Butler and Bonham 1963). Inevitably this deployment of technology could only occur in hospitals; and in large urban teaching hospitals. As one obstetric consultant from St Mary’s in London argued ‘To suggest that we should go back to the days of “home confinement” is like asking a modern surgeon to remove an appendix on the kitchen table.’ (Beard, The Times, 06.09.1974) and six years later, Davis was arguing that ‘the hazards of delivery are too many and too serious to subject both patient and midwife to the risks inherent in the obvious lack of medical facilities in the home.’ (The Times, 21.05.1980)

The path of maternity care in England between the 1960s and 1980s therefore seems clear. Hospital births outstripped home births, and maternal and perinatal mortality rates fell; obstetricians, and through them government documents, suggested a direct causal link. This is not the paper to discuss the merits of this argument; much work has been done by researchers suggesting that home births were never more risky than hospital births, and also that supposed links between hospital deliveries and mortality rates are coincidental at best (Tew, 1990). This paper will, however, explore the striking impact that women – as service consumers – had on the way arguments were framed, and ultimately on government policy. The language they used was not only very different, but increasingly influential. In the vanguard of this revolution in the debate about birth were well -off women living in urban areas; arguably, from a public health point of view, the group who had least medical need of specialist services.

The development of a consumer voice in maternity services

Feminist critiques of the history of birth have tended to suggest an oppositional relationship between (male) doctors and (female) service users in the post-war period with doctors using the language of risk and safety to coerce women into accepting high technology institutional births (Donnison 1988; Oakley 1980; 1984). Birth in hospital was led and controlled by doctors, with writers such as Oakley arguing that women were more or less tricked into giving up their hegemony over their experience. However, the evidence demonstrates that this was never the whole story. In urban areas, including Nottingham, Birmingham, Sheffield and parts of London, demand for hospital births by women always outstripped the availability of beds (McIntosh 2012). Midwives in Sheffield and London recommended women to book their hospital bed for birth within the first few weeks of pregnancy. Similarly in Nottingham and Derby the local health authority fought a rear guard action to remind women of the advantages of home birth over hospital birth, to little avail (McIntosh 2014).  In 1960, there was a debate in London about whether all women should have access to hospital beds; this was not for medical reasons but because women increasingly felt that they were ‘entitled’ to a hospital bed. The argument was made that women should be allowed to have their babies at home, but not forced to if they preferred hospital, and it was noted that these women tended to be ‘highly intelligent and provident women’ (TheTimes 12.2.1960). Looking back on the period, Jean Robinson, a campaigner for women’s rights in childbirth, argued that it was the ‘articulate middle class’ who got hospital beds even in times of shortage, because they booked early and believed the rhetoric about safety, and had the confidence to ask for what they wanted (interview with the author).

TaniaMcIntoshImageTwoIt was these same ‘articulate middle classes’ who were the driving force behind two influential health consumer groups which were set up in the late 1950s and early 1960s to promulgate specific views of the birth experience and are still in existence today; the National Childbirth Trust [NCT] and the Association for Improvements in Maternity Services [AIMS]. The NCT (formed in 1956 as the Natural Childbirth Trust) had been originally organised in order to help women to work with the system; in particular early NCT classes advocated relaxation and controlled breathing as superior to appearing out of control and in need of analgesia. The original aims of the Trust were clearly based round hospital care, and included the requirement that husbands should be present if desired, that analgesia should not be forced upon women and that they should be humanely treated. AIMs, set up in 1960, had at its beginnings in more polemical and strident fashion, when its founder Sally Willington wrote a letter to the Guardian newspaper saying:

In hospital, mothers put up with loneliness, lack of sympathy, lack of privacy, lack of consideration, poor food, unlikely visiting hours, callousness, regimentation, lack of instruction, lack of rest, deprivation of the new baby, stupidly rigid routines, rudeness, a complete disregard of mental care of the personality of the mother’. (The Guardian 01.04.1960)

She initially tried to call her group ‘the Society for the Prevention of Cruelty to Pregnant Women’, although was soon persuaded to change this for something with less negative connotations.

Both Willington, and Patricia Briance who set up NCT, had personal experience of hospital maternity care, both came from comfortable intellectual middle class backgrounds, and were comfortable using the language of ‘rights’. Briance later argued that ‘You cannot possibly imagine what it was like back then in fifties, we knew nothing about having a baby and there was no one to tell us; no books or magazines that told you what to expect’ (The Independent 26.04.1996).   No mention of midwives or of doctors; she offered a view that was not only stark but that reflected a particular agenda. A woman would expect to get information herself, not rely on professionals; both AIMs and NCT developed the concept of women not as patients but as consumers of the maternity services.  From the beginning, AIMs in particular was adept at harnessing the power of argument whether through letters to MPs, evidence to local committees, or talks to women’s groups. It boasted as members school teacher and welfare workers as well as consultants, surgeons and psychologists, and was granted an audience at the House of Commons just a year after coming into being (The Times 06.02.1961). Similarly, the NCT was good at making and using its contacts. In 1963, an interview with Betty Parsons, a teacher with the NCT commented on the ‘cordial relationship she has built up within the medical profession’ and a book she wrote on antenatal exercises had a ‘very complimentary’ Forward by John Peel, the President of Royal College of Obstetricians and Gynaecologists (who was later to Chair the committee calling for hospital beds to be available to all women) (The Times 01.04.1963). As Sheila Kitzinger – another childbirth campaigner and wife of an Oxford Don – remarked in interview, it was the relationships with Doctors that meant things got done (interview with the author). She commented very favourably on relations between herself and the obstetricians at the John Radcliffe Hospital in Oxford. Jean Robinson, who campaigned against unnecessary inductions of labour in the 1970s through AIMs, also spoke of her contacts; consultants in both London and Oxford. Clearly socially these women were on the same level as the doctors and politicians they dealt with and contacts could be informal and non-threatening. This gave them influence and power in developing and selling their view of childbirth.

The same often applied to the women who joined the NCT and AIMs or who used their services. One of the primary functions of the NCT was to run ante-natal classes in relaxation and childbirth preparation for women and their partners. As Betty Parsons commented, many of the lessons she gave were private one-to-one lessons; even the group sessions cost money. Nearly twenty years later Janet Balaskas, who had started off as an NCT teacher but now ran her own Active Birth movement in North London agreed that the women she dealt with belonged to a privileged group (interview with the author). However she argued that ‘Women like us can help effect changes for other women who don’t have our opportunities.’ Choosing to take lessons in natural or active birth was a huge commitment for women not just in terms of money, but time as well. One commentator explained in 1964 that a course of classes usually consisted of eight two hour sessions, plus daily practice, in order to be properly ‘trained’ (The Times 06.04.1964). This clearly was out of the reach of many women. The same commentator explained, rather scathingly, that although some classes were beginning to be offered on the NHS, a couple of sessions were not going to replicate the intensity needed to achieve success.

The issue of power and control is also clear during the early years of both AIMs and NCT. Women were only allowed to attend NCT classes if they had the permission of their doctor. The career of Janet Balaskas in many ways sums up some of these issues. She was radicalised by her own experiences of pregnancy and birth; shocked by what she felt was the medicalization of the English system she was in a position to return to her native South Africa to deliver. Even there, she asked permission of the doctor to have a natural birth. On her return, she trained as an NCT teacher, but was disillusioned with their continued acceptance that women should passive in labour and lie on their backs to deliver. In response she turned to yoga and began to develop what she described as ‘active birth’; encouraging women to stand and move for labour and squat for delivery. At this point she parted company with NCT because they considered her work ‘unproven’ and too ‘radical’ – in her words. In interview she talked about organising a rally in 1982 to protest at the refusal of the Royal Free Hospital in north London to allow women to have active births. She estimated that about 5000 people attended (Kitzinger suggested about 2500); including the wife of a member of Pink Floyd who donated stage and speakers, and the newsreader Anna Ford. At this point only two hospitals, both in well-heeled west London, and independent midwives offered active birth. Balaskas talked about change being incremental and word of mouth which only works in a tight geographical area; her classes still run in the same area of North London.

In interview Sheila Kitzinger used the language of control to describe the types of women attending NCT classes – ‘Mostly educated women. Women who were concerned about taking control of their lives and often it wasn’t just childbirth but other areas too that they were concerned with.’ The NCT and AIMS both developed a more radical agenda in the 1970s and 1980s, they increasingly argued against the use of technology. Although safety was always central to the rhetoric of the maternity services, and was particularly used to promote hospital birth and the use of technology, certain groups of women began to use different criteria to inform their experience of pregnancy and birth. This was partly based on personal experiences of technologically mediated birth. The language of feminism seems also to have been significant to many women in terms of the rights and control that they demanded over their own bodies. Equally important was the drive by some women for birth to be seen a psychological event as much as a physical one.

Kitzinger described the process of engagement with policy; radicalisation of women through demonstrations was one thing, real progress came through the media and through Government. She described learning to ‘…manage the media is a bit strong but learning to communicate with the media and express yourself with the media is a specific skill…’ She also talked about putting pressure on Parliament, and getting questioned of MPs and by MPs. These were all particular class and social skills, and Kitzinger and others argued that the work they did made a difference to all women. As Balaskas commented, birthing pools and space to practice active birth are now encouraged in NHS facilities and supported by midwives; this could be seen as the positive impact of the work of an elite. However, it could also be seen as at best an irrelevance; women from low income backgrounds and ethnic minorities continued to have the highest rates of perinatal and maternal morbidity and mortality; birthing balls and pools made little impact on their needs for responsive care (Confidential Enquiry Reports).

TaniaMcIntoshImageThreeThe impact of the consumer voice on relations with health professionals

Relationships between midwives, doctors and women were complex, and the stories told about maternity care from each perspective do not always tally. To women, midwives and doctors could be cold and bossy, or deeply warm and caring. To the midwife, women could be unnecessarily demanding or laughably ignorant. Both groups used shorthand and concepts of heroic attitudes or behaviour to describe characteristics of the other, in a way that made sense and made a complex and symbiotic relationship more manageable.

Certainly there were groups of midwives who were instrumental in developing a radical language and in working alongside women, in particular the Association of Radical Midwives which was formed in 1976 by a group of student midwives, who themselves felt oppressed by the system under which they worked. In terms of change, however, their efforts were dismissed by some of the consumer campaigners; Kitzinger argued that they were not a major influence on changes in maternity care, although Balaskas said that she would always support the right kind of midwife; one not driven by fear or policy.

However, midwives were often seen by women as being part of a discredited system, and this impacted on the relationship between mother and midwife. Jean Robinson who worked for AIMs remarked that, ‘midwives sold women down the river’ because they were seen as part of the medical establishment, rather than being ‘with woman’ as the name ‘midwife’ suggested they should be. She argued that AIMs and other consumer groups ‘were hampered not just by the arrogance of the medical profession and their entrenched and undeniable power, but by the weakness of the midwives…they are not fighters and they do not think strategically.’

It is certainly true that many midwives were excited by the possibilities of technology, and embraced its cutting edge nature enthusiastically. One who worked in Manchester described how in 1967 their hospital was the first one in England to have an electronic fetal heart monitor – ‘of course it was exciting, we’d never seen a foetal heart monitor before… I thought everyone should have the benefit of technology’ (Stella; interview with author). This seems to have been particularly true of hospital midwives. For Kitzinger, however, it was more about a state of mind:

Well many midwives were very authoritarian and thought that it was a sort of games mistress approach almost, that you had to behave yourself as if you were on a hockey field and obeyed the rules, otherwise everything would go to pot.

There was also a pride among midwives that they were professionals and did know best; one midwife who worked in Manchester in the 1970s felt that many women had their expectations of pregnancy and birth raised by consumer groups, and that any resource to technology or assistance constituted ‘failure’. There was also pride among midwives who worked in rural communities that they knew ‘their’ women well, and the relationship was an individual one rather than needing to be mediated through the language of ‘control’ or ‘rights.’

One midwife, Jenny, who worked in Nottingham in the 1970s and 1980s said that she felt relationships between women and midwives were good in the 1970s because ‘They didn’t have the expectations that they have now, and trusted you I think probably.’ The move from ‘patient’ to ‘consumer’ affected midwives because they felt their professional status was being eroded. Littleford described the impact that this had on their work and on their professional standing; ‘I think the women’s and families expectations were far greater than we could ever provide.’ This she attributed to Government policy and to the demands of women, but also the squeeze between expectations and the ability of the service to cope. This included not just lack of staff and equipment, but lack of respect by doctors, particularly in the large teaching hospitals, for the work that midwives did. Littleford felt midwives were regarded as pliable handmaidens both by doctors and increasingly by some women; and that their demands could be incompatible.

Within the rhetoric of urban consumer groups and radical midwives there was no attempt to include the voices or needs of non-middle class members of the community such as women from low income families, refugees, teenage mothers or single mothers. Mavis Kirkham, who worked as a hospital midwife in Sheffield in the 1970s, described consciously deploying ‘nice middle class’ couples to pioneer partners being present in theatre for elective caesareans. Within her work, she spoke of ‘misfits’ coming together; not just midwives who did not fit the system but women as well. Again, she argued that change came incrementally; through individuals attending antenatal classes, or booking with a certain community midwife. In many ways these were still an elite self-selected group; women who were articulate and well-read and confident enough to demand a particular kind of care. In contrast, Oakley’s work on the experience of first time pregnancy and motherhood, conducted between 1975-6, demonstrates that women continued to be accepting of the system as it was (Oakley 1981; see also Cartwright 1979). This was not to say they were always happy with it, but they had no language for criticising the system, and no sense that they could change it. McIntosh (1989), in a study of motherhood on urban Glasgow, found that women did not invest the act of birth with huge significance; it was only a tiny part of the larger experience of motherhood. These were ordinary women living in an urban environment; not people with the confidence to right to MPs or the money to buy into a philosophy such as active birth.


The consumer movement in maternity really developed from the 1960s onwards, and had a significant impact on the language and beliefs around birth by both policy makers and professionals. The evidence suggests that urban elites who developed consumer groups in maternity had an influence on the discourse around pregnancy and birth beyond their numbers. This included debates around the types of care offered; hospital birth, the use of technology and the development of active and low tech births. Although the arguments around active birth have been foregrounded in this paper, some women also campaigned for greater access to induction of labour and the provision of epidurals. The consumer voice was always complex and multifaceted. Similarly successive governments, taking their cue from obstetricians, had used medical concepts of ‘safety’ and ‘risk’ to frame policy since the early 1960s. However from the 1990s policy makers began to use phrases such as ‘choice’ and ‘control’ in relation to maternity which consumer groups had been using for twenty years. Arguably women did begin to take control of childbirth across the period, but in a way which spoke to a small, elite, cross-section of society. Although some midwives developed their own radical agenda around birth, for others the voice of the consumer represented a threat to their sense of professional identity and confidence. The move to hospital birth and demands for different kinds of birth marginalised the role of midwives, leaving them sandwiched between doctors and women.

Dr. Tania McIntosh, Principal Lecturer, School of Health Sciences


All oral quotes are from interviews with author

Butler, N.R. and Bonham, D.G. (1963) Perinatal Mortality: The First Report of the 1958 British Perinatal Mortality Survey, under the auspices of The National Birthday Trust Fund, London: E. & S. Livingstone Ltd.

Cartwright, A (1979) The Dignity of Labour? A Study of Childbearing and Induction, London: Tavistock Publications Limited

Donnison, J. (1988) Midwives and Medical Men: A History of The Struggle for the Control of Childbirth, 2nd edn, London: Historical Publications

Department of Health (1970) Domiciliary Midwifery and Maternity Bed Needs, London: HMSO

Macfarlane, A., Mugford, M., Henderson, J., Furtado, A., Stevens, J. and Dunn, A.(2000) Birth Counts: Statistics of Pregnancy and Childbirth, Volume 2 – Tables, London: The Stationary Office

McIntosh, J. (1989) ‘Models of childbirth and social class: a study of 80 working class primigravidae’, in Robinson, S. and Thompson, A.M. (eds) (1989) Midwives, Research and Childbirth: Volume 1, London: Chapman and Hall

McIntosh, T (2012) A Social History of Maternity Care, Abingdon: Routledge

McIntosh, T (2014) “I’m not the tradesman”: A Case Study of District Midwifery in Nottingham and Derby 1954-1974”, Journal of the Social History of Medicine, doi: 10.1093/shm/hku011

Ministry of Health (1956) Report of the Maternity Services Committee, London: HMSO

Oakley, A (1980) Women Confined: Towards a Sociology of Childbirth, Oxford: Martin Robertson

Oakley, A(1981) From Here to Maternity: Becoming a Mother, Harmondsworth: Pelican Books

Oakley, A (1984) The Captured Womb: a History of the Medical Care of Pregnant Women, London: Wiley-Blackwell

Shorter, E. (1983) A History of Women’s Bodies, London: Basic Books

Tew, M. (1995) Safer Childbirth? A Critical History of Maternity Care, 2nd edn, London: Nelson Thornes



Wednesday 22nd July 2015

Practitioner role resilience: applying a 5th wave collaborative approach to support the early career phase.

Caroline Hudson Senior Lecturer


A ‘critical point’ for practitioner resilience is the early career phase (Hunter and Warren, 2014), otherwise termed the preceptorship period. Tailored to the needs of novice professionals (preceptees), the preceptorship literature has focused on the preceptees’ experience without addressing the adversity faced by the experienced professionals (preceptors), or their support needs (Muir et al, 2013). Challenges to the preceptor role are regularly referred to in the literature, including role strain, time restraints and workload pressures (Rooke, 2014; Morton, 2013; Chen et al, 2011).

Given the potential for role fatigue and preceptor burnout (Blozen, 2010), and the transitional stress for novice professional, practitioner resilience can be defined as the capacity to withstand and change adversity in practice (emerging 5th wave of resilience researchHart, Gagnon, Aumann, & Heaver, 2013). This participatory study seeks to capture the counter-narratives of both preceptees and preceptors to determine what positively influences preceptorship relationships, using realist evaluation to examine, ‘What works for whom, in what circumstances and in what respects, and how?’ (Pawson and Tilley, 2004 p2). Based on Heron’s (1996) earlier co-inquiry process, this thesis involves researching alongside preceptees and preceptors as co-researchers.

Co-researchers will identify ways of challenging and overcoming some of the issues, and co-produce knowledge leading to outputs, such as a Preceptorship Resilience Framework. Co-researchers will be involved in the research process throughout the study, and this will be as important to the research design as to the findings. This presentation reports on the early phases of a collaborative study on practitioner resilience, linking with the resilience research and practice programme, co-ordinated by Professor Angie Hart and collaborators ( and will share some of the innovative approaches to researching alongside co-researchers at the early stages of a doctoral thesis.

Reference and resources:

Chen, Y., Duh, Y., Feng, Y., & Huang, Y. (2011). Preceptors’ Experiences Training New Graduate Nurses: A Hermeneutic Phenomenological Approach. Journal of Nursing Research, 19(2), 132–40.

Hart, A., Gagnon, E., Aumann, K., and Heaver, B. (2013). in Uniting resilience research and practice development with activism to challenge social adversity. Resilience forum presentation by Hart and Gagnon Accessed 11/01/15 Available at:

Hunter, B. and L Warren. (2014) Midwives experiences of Workplace resilience. Midwifery 30(8):92-934

Morton, S. (2013). What support do Health visitor mentors need? Community Practitioner, 86(8), 32–35.

Muir, J., Ooms, A., Tapping, J., Marks- Maran, D., Philips, S., and Burke, L. (2013). Preceptors’ perceptions of a preceptorship programme for newly qualified nurses. Nurse Education Today, 33, 633–638 .

Pawson. R. and N. Tilley. (2004) Realist Evaluation. Sage: London

Rooke, N. (2014). An evaluation of Nursing and midwifery sign off, new mentors and nurse lecturers’ understanding of the sign off mentor role. Nurse Education in Practice, 14(1), 43–8


Caroline Hudson – I am a Senior lecturer in the School of Health Sciences with a nursing background and an MSc in Professional Health Care Education. I have worked at the University of Brighton, for over 10 years and lead on practice based education programmes and embedding resilience across curriculum. I am currently undertaking a PhD doctoral study, entitled, ‘A realistic evaluation of role resilience in preceptorship: development of a Preceptorship Resilience Framework using a co-operative inquiry process’ and have a special interest in developing practitioner resilience using collaborative research approaches.

Keywords: Role resilience, Practitioners, Preceptorship, realist evaluation and co-researchers


Wednesday July 8th 2015

Pre-registration student nurses’ collaborative e-learning exploring the role of the clinical research nurse

Ian Taylor Senior Lecturer


This presentation will detail an informal evaluation of blended learning activities developed and implemented in a level five pre-registration nursing module ‘Developing Clinical Research Nurse Careers’.  This module aims to develop in students an understanding of the role of the clinical research nurse, career pathways for research nurses, and their relevance for practice.  The digital transformation of its courses is a key aspiration of the University of Brighton, supported by the creative and innovative use of technologies for learning, teaching and research.  Blended learning generally incorporates the use of online media with traditional face-to-face contact with students, and may offer more satisfactory learning outcomes than either face-to-face approaches or stand-alone online media.  The SOLO taxonomy was applied to the module design to help match students’ activities with the intended learning outcomes through a process called ‘constructive alignment’.  This involved balancing and matching the module learning outcomes with students’ blended learning activities and the assessment task.  These were closely aligned to promote students’ deeper understandings of traditionally ‘dry’ key concepts, and to apply them to the professional context of the clinical research nurse.  Use of blended learning approaches was evaluated positively by students who achieved higher than average grades and pass rates in the module summative assessment when compared to modules using traditional learning and teaching approaches alone.


Dr Ian Taylor is a Senior Lecturer in the School of Heath Sciences.  His professional nursing background is in acute inpatient services, community mental health nursing and substance misuse, within the NHS in Scotland.  Ian has been involved in nurse education since 1996. His teaching interests include undergraduate continuing professional development research and evidence based practice teaching within the School.  Most recently, Ian has developed an interest in blended learning approaches and has designed and implemented an innovative Clinical Nurse Research Careers module for pre-registration nurses on the BSc (Hons) Nursing programme. Ian received an Excellence in Facilitating/Empowering Learning award from the university in 2014, recognising his commitment to students to work creatively to improve the quality of their learning.


Wednesday 24th June 2015

Searching for Equity in Health Visiting Perinatal Mental Health Policy, Services and Practice Using Case Study Research.

Palo Almond Senior Lecturer


Research studies have shown that there are efficient and effective methods to assess and screen women for postnatal depression and there are also a range of effective ways to treat women using talk based and/or pharmacological interventions.  However the literature has shown that whilst some women are screened or assessed by health visitors, GPs or midwives there are many who are not. A research study was designed to try and understand why inequity in service provision existed. The aim of this presentation is to describe the way CSR was used a strategic framework to plan and implement the study rather than the findings.


Single case with embedded cases.

Sample and Data Collection

  • Observations of 21 home visits involving screening, assessment or treatment of women with postnatal depression.
  • interviews with 20 Health visitors,
  • Interviews with 6 managers and team leaders
  • Interviews with 9 Bangladeshi women (some were had British citizenship)
  • Interviews with 12 British women (all white)
  • Policy, Business plans and other documents

Data Analysis

Thematic analysis using Framework Analysis methods of interview data and documents.


Dr Palo Almond recently joined the University of Brighton having previously held posts at the King’s College London, University of Southampton and Anglia Ruskin University where she led primary care and public health departments and programmes or conducted PH related research. Her role here is to draw on her public health research and scholarship to support the Specialist Community Public Health Nursing courses, contribute to public health teaching and lead on the development of a new BSc (Hons) in Public Health which is to be delivered from the new Hastings campus. Dr Almond’s research, scholarship and pedagogy has largely centred on public health, health promotion, maternal mental health, child health, and more recently suicide prevention in adolescents and young people. Palo’s preferred methodologies are qualitative however she has led on a RCT incorporating surveys and qualitative elements and written a book on Interpreting Statistics a Guide for Health Professionals and Students (Walker J and Almond P 2010).

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